Provider Demographics
NPI:1205855871
Name:WILSON, CURTIS WINFRED (CRNA)
Entity Type:Individual
Prefix:
First Name:CURTIS
Middle Name:WINFRED
Last Name:WILSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 40
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31776-0040
Mailing Address - Country:US
Mailing Address - Phone:229-891-9131
Mailing Address - Fax:229-891-9079
Practice Address - Street 1:3131 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6925
Practice Address - Country:US
Practice Address - Phone:229-891-9131
Practice Address - Fax:229-891-9079
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2008-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAR086052367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00693063BMedicaid
GAR086052OtherLICENSE
GA000693063DMedicaid
GA000693063CMedicaid
GAR086052OtherLICENSE
GA000693063DMedicaid
GA511I430523Medicare PIN
GA43BBCTDMedicare PIN